A CMS proposal to grow the Comprehensive Care for Joint Replacement model nationwide would hold hospitals accountable for Medicare spending tied to joint replacement procedures and the 90 days following surgery, including post-acute care.
It also aims to improve care coordination and reduce unnecessary services such as avoidable rehospitalizations and emergency visits.
Orthopedic leaders discussed what this move means for the specialty.
Note: Responses were lightly edited for clarity.
Question: CMS proposed expanding its Comprehensive Care for Joint Replacement model nationwide through the fiscal year 2027 hospital inpatient and long-term care payment rule. What does this mean for the specialty and its future?
Cory Calendine, MD. Bone and Joint Institute of Tennessee (Franklin): Most notably, this move means bundled payments are no longer optional. Yes, the American Hospital Association has already raised concerns and the comment period is open until June 9th, but the direction CMS wants to go is clear.
CJR-X will necessitate alignment across the 90-day care episode. The most successful CJR programs have already taught us that there must be tight coordination between surgeons, anesthesia, PT, navigators, and post-acute partners. Since every acute care hospital in the country must participate, the question is whether every hospital has the means to invest in and organize this coordination, or will care be driven to larger facilities with the infrastructure to support it? I lean toward predicting the latter. If so, access to care will be an issue at some point. Limited access to care will limit healthcare spending, which is a noble goal, but not a noble way to achieve it.
Kevin Fleming, vice president at Orthopedic Institute, AdventHealth (Orlando): I am actually excited about the opportunities that the proposed national expansion of the CJR model could offer to CMS, providers, physicians, and, most importantly, patients. The original CJR model, which launched in the mid-2010s, showcased that aligning incentives to focus on the costs of healthcare could effectively bend the cost curve and generate real savings through reduced spending on unnecessary clinical variation and a focus on driving the clinical outcomes that matter to patients, like reduced readmissions and complications from care.
While the final details will always matter, I am cautiously optimistic that a national program like this can position CMS to more effectively evaluate and design innovative models of care, and at a national scale, that reward those focusing on a coordinated, equitable, and high-value care experience for patients.
Michael Gross, MD. Union Middlesex Orthopedics (Middleton, Conn.): Arthroplasty becomes even more episode-driven, not procedure-driven. The specialty will be judged less by implanting a joint well and more by total episode cost, readmissions, infection, discharge disposition, and 90-day recovery.
PJI prevention becomes financially central, not just clinically central. Under bundled payment logic, infection is the complication that most dramatically destroys both patient outcome and episode economics.
Expect more standardization of pathways: prehab/optimization clinics, implant rationalization, discharge-to-home programs, and tighter post-acute network management.
Surgeons who can manage variation will lead. The future practice advantage will come from risk selection, optimization of medically complex patients, and collaboration with anesthesia, medicine, ID, and post-acute partners.
The potential downside is increased pressure to avoid high-risk patients unless the model sufficiently risk-adjusts for infection risk, frailty and revision complexity.
The specialty must balance cost containment with maintaining access for vulnerable populations, requiring risk stratification methodologies that account for medical and socioeconomic complexity. Success will depend on active surgeon engagement, institutional alignment around value-based principles, and continued innovation in care delivery models that genuinely improve patient outcomes while controlling costs.
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